Annual Eye Health Exam Eye Care Associates of Princeton DATE :

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1 Annual Eye Health Exam Eye Care Associates of Princeton DATE : First Name: Last Name: Male/Female (circle) Date of Birth: Age: _ Employer: Occupation: Address: City: State: Zip: Cell Phone Number: May we text you? 2nd Phone: Home/Cell/Office (circle) Address: (office use only) If you provide an address, we will only use it to send patient appointment reminders, recalls, a patient survey after your visit, and a clinical summary of your exam today. We will not give your address to any other entity. When was your last eye exam? Are you diabetic? Reason for your visit: If your visit is of a problem based nature, your vision coverage will not cover this visit. Please let the front desk know so that we may properly direct your care and determine your eligibility for medical insurance coverage which may differ from your vision coverage. Annual Eye Health Exam Your annual eye exam will provide you with an assessment of your vision based on the findings of your AccuExam and the information gathered during your evaluation with your Doctor. In addition, the Optomap retinal exam is our Doctors choice of retinal evaluation for every patient at every annual exam. Your Optomap exam will give you a thorough retinal exam without the dilation drops, the blurry vision, and extra time needed. The retinal images assist in detecting and measuring subtle changes in your retina at your annual exams. Your retinal images are stored in your electronic health records and are yours permanently for physician referrals, if needed. If you request, we will happily your images to you within 48 hours of your visit here at the office. Please provide an address above. The fee for the annual Optomap retinal scan is 29$ and will not be covered by your insurance. Ocular Wellness Screening In addition to your annual eye exam, our office recommends you have an annual Ocular Wellness Screening which will give our Doctors and you a full picture of your retinal and macular health. Recommended annually for all patients with a personal or family history of glaucoma, macular degeneration, diabetes, and other ocular conditions are strongly recommended to opt for the Ocular Wellness Screening. 40$. Accept Decline Contact Lens Annual Evaluation ( ) Y ( ) N Are you a contact lens wearer or would you like to be one? If so, there is an additional fee for annual contact lens evaluation which usually ranges between $80.oo and $150.oo, and includes trial pairs of lenses and a follow up period of three months of care for your contact lens prescription. The annual fee for contact lens evaluation is applicable to both existing contact lens wearers and to those patients new to contact lens wear. This fee is generally not covered by medical insurance. Please see the front desk with any questions. Also, if you currently wear contacts, what brand do you wear? We are happy to announce that we are fully participating in EMR and the HiTech Act in our office! To continue the process, we are required to ask you for a few questions. Please circle below. Language: Communication: Ethnicity: Race: English Postal Decline to specify American Indian/Alaska Native Native Hawaiian French Telephone Hispanic or Latino Asian Pacific Islander Japanese Native Hawaiian/Pacific Isl. Black or African American Other Spanish Not Hispanic or Latino Declined to specify White Hispanic

2 PAST, FAMILY, AND/OR SOCIAL HISTORY: Is there a member of your immediate family who has any ocular issues, including glaucoma, cataracts, macular degeneration, etc. No (circle) Yes Mother Father Brother Sister Daughter Son Condition and when: Is there anything in your past history, extended family history, or social history which would help us take care of you? Social History Do you smoke? (N) (Y) If yes, how much? pack a. Do you drink alcohol? (N) (Y) If yes, how much/often? drinks a. Past History (illnesses, operations, injuries, medications, treatments) ( ) N ( ) Y Extended Family History (diseases, hereditary, risk factors, glaucoma) ( ) N ( ) Y Eye Surgeries (What, when, which eye, etc.) (explain below) ( ) N ( ) Y CURRENT MEDICATIONS (Please list briefly the current medications you take.) MEDICATION ALLERGIES: PRIMARY PHYSICIAN: PHONE: Eyes Y N Allergic/Immunologic Y N Hematological /Lymphatic Y N Blindness ( ) ( ) Hay Fever ( ) ( ) Anemia ( ) ( ) Blurred Vision ( ) ( ) Medicine allergies ( ) ( ) Bleeding problems ( ) ( ) Burn/itching ( ) ( ) Cardiovascular Swelling ( ) ( ) Cataracts ( ) ( ) Heart Problems ( ) ( ) Immunologic Crossed eyes ( ) ( ) High Blood Pressure ( ) ( ) Herpes Simplex ( ) ( ) Double Vision ( ) ( ) Vascular disease ( ) ( ) Influenza ( ) ( ) Dry eyes ( ) ( ) Constitutional Sjogren s Syndrome ( ) ( ) Eye Injury ( ) ( ) Fevers ( ) ( ) Integumentary Eye Pain ( ) ( ) Weight Loss ( ) ( ) Breast cancer ( ) ( ) Eye Surgery ( ) ( ) Problems sleeping ( ) ( ) Dry skin ( ) ( ) Flashers ( ) ( ) Endocrine Musculosketal Floaters ( ) ( ) Diabetes ( ) ( ) Arthritis ( ) ( ) Glare ( ) ( ) Thyroid problems ( ) ( ) Fibromyalgia ( ) ( ) Glaucoma ( ) ( ) Gastrointestinal ( ) ( ) Joint pain ( ) ( ) Halos ( ) ( ) Constipation ( ) ( ) Muscle Pain ( ) ( ) Light Sensitivity( ) ( ) Diarrhea ( ) ( ) Neurological Loss of vision ( ) ( ) Genitourinary Headaches ( ) ( ) Mucous ( ) ( ) Bladder infections ( ) ( ) Migraines ( ) ( ) Red eyes ( ) ( ) Frequent urination ( ) ( ) Seizures ( ) ( ) Sandy or gritty ( ) ( ) Kidney infections ( ) ( ) Psychiatric Tired eyes ( ) ( ) Head Compulsive behaviors ( ) ( ) Vision therapy ( ) ( ) Allergies/Hay Fever ( ) ( ) Depression ( ) ( ) Watery eyes ( ) ( ) Sinus problems ( ) ( ) Nervous disorders ( ) ( ) Chronic cough ( ) ( ) Respiratory Chronic ear infections ( ) ( ) Asthma ( ) ( ) Dry throat/mouth ( ) ( ) Emphysema ( ) ( ) Rev

3 Eye Care Associates Financial Policy rev. 1/2016 Our annual eye exam fee for patients not using insurance is $ which includes an AccuExam and Optomap Retinal Exam. Additional fees apply to patients who wear contacts lenses and/or those choosing the optional Ocular Wellness Screening. The Optomap differs from the Ocular Wellness Screening. Please see the front desk with questions. For patients using insurance, the fee is comprised of their copays as directed by their individual coverage and the fee for Optomap which is $ The Optomap Retinal Exam is given to every patient with every annual exam and will not be covered by insurance. Additional fees apply to patients who wear contacts lenses and/or those choosing the optional Ocular Wellness Screening. The Optomap differs from the Ocular Wellness Screening. Please see the front desk with questions. The Ocular Wellness Screening is recommended for patients over the age of 18 with risk factors for glaucoma, macular degeneration, and diabetic retinopathy among other ocular pathologies. This screening will not be covered by insurance and the fee is $40.00 for both insured and non insured patients. If you have any questions about your vision coverage or it is not a time of day or day of the week that we can verify vision benefits, we strongly encourage you to pay our out of pocket fee of $ rather than having us bill the insurance company. If we do so, and your claim is denied for any reason, we will have to bill you the balance not covered by insurance which is higher than our private pay discounted exam. You may take the receipt to submit for possible insurance reimbursement following your exam. All fees are due at the time of service. All contact lens orders must be paid in full at the time of order placement. Patients who are seen for an eye exam in our office, resulting in a glasses prescription, are entitled to come in for one prescription check visit within 30 days of the initial exam. Any visits after that one will be billable visits at $45.oo each. Contact lenses may be returned for full credit if unopened, unmarked, unexpired, if purchased from our office, and within one year of the purchase. They must not have an expiration date within two calendar years of the return date. CONTACT LENS EVALUATIONS ( ) Y ( ) N Are you a contact lens wearer or would you like to be one? If so, there is an additional fee for annual contact lens evaluation which usually ranges between $80.oo and $150.oo, and includes trial pairs of lenses and a follow up period of three months of care for your contact lens prescription. Specialty or complex evaluations requiring custom made lenses may be higher. The annual fee for contact lens evaluation is applicable to both existing contact lens wearers and to those patients new to contact lens wear. Contact lens evaluations are considered by insurers to be cosmetic or non-medically necessary procedures except in rare circumstances. This fee is generally not covered by medical insurance and you will be required to pay for any difference in fees beyond what your insurance provides. Please see the front desk with any questions. All contact lens evaluation fees cover visits for contact lens checks for three (3) months. Any visits for contact lens appointments after the 3 month follow up period will be billable visits at $45.00 each. Visits for other reasons during that 3 month period of time will not be covered by the contact lens evaluation fee and will be billable with fees depending on complexity of the visit. REGARDING INSURANCE Our office has contracts with Aetna, Horizon Blue Cross/Blue Shield, Medicare, and United HealthCare for medical coverage and EyeMed, Humana, and Superior Vision for vision coverage. We can also bill to VSP as an out of network provider. Medicare patients should provide their Medicare card and the card for their supplemental or other insurance. You will be required to satisfy your annual $166 deductible and pay your 20% copayment plus any other non-covered services provided. Additionally, all fees for any services which are not covered by Medicare will be due at the time of service. If you are using insurance, you must present your insurance card when you check in or you will be personally responsible for all charges and for obtaining any reimbursements due from your insurance carrier. No claims will be filed with insurance if presented after the service date, including to secondary insurance. Our policy is to make every effort to bill your insurance but no claim payment is guaranteed, even with a preauthorization. We ask that you understand your benefits prior to scheduling in order to avoid incurring additional fees. IF YOU ARE NOT USING INSURANCE, you will be required to pay the entire bill for services provided at the time of service. Please sign and date at the bottom. IF YOU ARE USING INSURANCE, please fill in the information below and sign and date at the bottom. Patient name: Patient Date of Birth Subscriber s name: Subscriber s Date of Birth Name of the insurance Member # I have read the Financial Policy. I understand I can ask questions if any part is not clear. My signature below indicates I agree to its terms. Signature of Patient or Responsible Party Print Name of Patient Relationship/Authority of Responsible Party Date

4 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. This Notice takes effect July 1, 2014, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. In the event we make a material change in our privacy practices, we will change this Notice and provide it to you. You may also request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION We may use and disclose health information about you for treatment, payment, and healthcare operations. Treatment: We may use or disclose your health information to an optician, ophthalmologist or other healthcare provider providing treatment to you. For example, we may use and disclose protected health information or ( PHI hereafter) when you need a prescription or when you need to be referred to a specialist for consultation. Prescription information may be given to another optician, ophthalmologist, other healthcare provider or pharmacy. Payment: We may use and disclose your health information to obtain payment for services provided to you. Generally, we may use and give medical information to others to bill and collect payment on services rendered. Before a patient receives scheduled services, we may share information about these services with your health plan(s), to obtain eligibility information and/or to get the required preapproval. We may also share information with your health plan(s) once services are rendered and the appropriate health insurance claims must be filed. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include things such as quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Without Your Authorization: We may use and disclose PHI about you under a number of circumstances without your consent or without your right to object. Those circumstances include: When use or disclosures are required by law (i.e. federal, state or local law or other judicial or administrative proceedings). When the use or disclosure is necessary for public health purposes, (i.e. if you have been exposed to a communicable disease or may otherwise be a risk to the community). When the disclosure relates to abuse, neglect or domestic violence. When the disclosure relates to decedents (i.e. coroner or medical examiner) or for organ donation. When the use or disclosure is for medical research. Lastly, when the use or disclosure is needed for an emergency. With Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. Marketing Health Products or Services: We will not use your health information for marketing communications without your prior written authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will never sell your health information without your prior authorization. Disclosing Healthcare Information to you or a Third Party: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment.

5 Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, contact lenses or other similar forms of health information. Appointment Reminders and Treatment Alternatives: We may use or disclose your health information to provide you with appointment reminders or routine exam reminders (such as voic messages, postcards, or letters) or information about treatment alternatives or other health-related benefits and services that may be of interest to you. PATIENT RIGHTS Access: You have the right to review or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to or receive copies of your health information. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may submit your request to the address at the end of this Notice. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Please feel free to contact us using the information listed at the end of this Notice for a full explanation of our fee structure. There are certain circumstances in which we are not required to comply with your request. We will respond to you in writing stating why we will not grant your request and describing and rights you may have to request review of our denial. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, where you have provided an authorization and certain other activities, for the last 6 years, but not for disclosure made prior to April 14, If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. Electronic Notice: If you receive this Notice on our Website or by electronic mail ( ), you are entitled to receive this Notice in written form as well, per your request. If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. Contact Person: Suzanne Mullarney Telephone: (609) Fax: (609) sjmullarney@icareassociatesprinceton.com Address: Eye Care Associates of Princeton Princeton Market Fair, Suite U.S. Route One Princeton, NJ ACKNOWLEDGEMENT OF RECEIPT I acknowledge that I have read and received a copy of Eye Care Associates of Princeton, P.C. Notice of Privacy Practices.

6 Patient Name: (Please Print) Signature: Date: For Office Use Only We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because: Individual refused to sign. Communication barriers prohibited obtaining the acknowledgment. An emergency situation prevented us from obtaining acknowledgement. Other: